1. miUlli UROLOGY CHIRURGIA ROBOTICA E QUALITA’ DI VITA
Ente Ecclesiastico
Ospedale Generale Regionale “F. Miulli”
Acquaviva delle Fonti
Struttura Complessa di Urologia
Centro di Chirurgia
Robotica - Laparoscopica – Mininvasiva
Direttore: Giuseppe Mario Ludovico
UROLOGY
miUlli
DEPARTMENT
CHIRURGIA ROBOTICA E QUALITA’ DI VITA
Giuseppe Mario Ludovico
Martina Franca 15 dicembre 2012

2. UROLOGY
miUlli
DEPARTMENT
The most updates European Association of Urology (EAU) guidelines report about:
bilateral nerve-sparing radical retropubic prostatectomy (BNSRP)
unilateral nerve-sparing radical retropubic prostatectomy (UNSRP)
represent the recommended approach of choise in all men with both a normal preoperative erective-function (EF) and organ confined disease
Heidenreich A., Bellmunt J, et all; EAU GUIDELINES; 2011

3. UROLOGY
miUlli
DEPARTMENT
Since the introduction of Patrick Walsh’s tecnique, open radical prostatectomy (RP) is the standard surgical treatment of localised Pca.
Walsh PC: J Urol 2000
...WHICH ARE THE OUTCOMES AFTER RADICAL PROSTATECTOMY FOR A LOCALIZED PROSTATE CANCER ?

4. UROLOGY
miUlli
DEPARTMENT
The current robotic literature reveals 12-months potency outcomes favorable (70 to 80%) with the robotic approach and comparable to even longer term (24 months) data of expert open series (46% to 54%).
Berryhill R. Jr, Jhaveri J et al: Urology 2008
Ficarra V., Novara G. et al: Eur Urol. 2012
Box GN Ahlering TE: Curr. Opin. Urol 2006
3-month potency outcomes (46% to 54%) seem to suggest the relatively rapid return of erectile function,
Box GN Ahlering TE: Curr. Opin. Urol 2009 4

5. UROLOGY
miUlli
DEPARTMENT
Comprehensive review including RRP series pubblished between 1990 and 2005 showed a wide range of recovery of erectile function after a minimun follow up of 12 mo., in patients who received bilateral NSRRP showing potency rates ranging from 31% to 86%.
Dubbelman YD, Dohle GR, et all: Eur Urol 2006
Comprehensive review including RRP series pubblished before 2005 showed that the prevalence of erectile dysfunction according to difference definition was 47,8% after RRP and 24,2% after RARP.
The cumulative analysis showed a statistically significant advantage in favour of RARP
( OR :2,84; 95% CI: ,43; p= 0,002).
Ficarra V, Novara G et al: BJU Int, 2009
Di Pierro GB, Baumeister P et al: Eir. Urol., 2011
Kim Sc, Song C: Eur urol., 2011
Rocco B., Matei DV et al: BJU Int, 2009

6. UROLOGY
miUlli
DEPARTMENT
The real problem isn’t this: If the open radical prostatectomy is better than robotic radical prostatectomy, we’ll obtain or not nerve preservation but this one:
How we’ll perform a TRUE NERVE SPARING PROCEDURE? or
..Where are really the NVBs?

7. UROLOGY
miUlli
DEPARTMENT
New anatomic concepts distribution and course of the cavernous nerves, New anatomic tecniques anterior incision of the periprostatic fascia inter- or intrafascial surgical planes New devices thermal or athermal dissection of the neurovascular bundles i.e. monopolar vs bipolar vs clips, cold dissection, countertraction Surgeon’s experience case-load, high volume centre, learning curve Costs

8. miUlli UROLOGY New «anatomic concepts»
Initially, Walsh’s description of the anatomic nerve-sparing tecnique in 1982 was based on the concept that the neurovascular bundles (NVBs) are situated posterolaterally and simmetrically to the prostate in the space among the levator fascia, prostatic fascia and Denonvillier’s fascia.
Walsh PC, Donker PJ et all.:J. Urol. ,1982
In the last decade, deeper insight into the the distribution and course of the cavernous nerves showed that, especially in men with a small prostate, NVBs may have either an anterolateral position or, rarely, an asymmetric posterolateral position on one side while lateral on the other.
Menon M., Tewari A. et al: J Urol 2003
Kiyoshima K. Yokomizo A. et al: Jpn J Clin Oncol, 2004
Tewari A, Rao S. et al: BJU Int, 2008
DEPARTMENT

9. miUlli UROLOGY New «anatomic concepts»
DEPARTMENT
These new anatomic concepts supported the incision of the periprostatic fascia anteriorly and parallel to the NVBs preserves cavernous nerve located at both the posterolateral and anterolateral surfaces of the prostate.
Menon M., Tewari A. et al: J Urol 2003
The multiple compartments that could be developed from the levator fascia to the prostate capsula by entering fascial planes during surgery explain the possibility of realizing a different extension of the nerve-sparing procedure according to cancer risk stratification and patient preoperative characteristics
Tewari A., Rao S. et al: BJU Int, 2008

10. miUlli UROLOGY New «anatomic concepts»
DEPARTMENT
Graefen et al and Montorsi et al demonstred the feasibility of the anterior incision of the periprostatic fascia and the possibility of realizing an interfascial or intrafascial surgical plane in open surgery.
Graefen M. Walz J. et al: Eur Urol, 2006
Montorsi F., Salonia A. et al: Eur Urol, 2005
The influence of anterior periprostatic nerve tissue suggests the use of a more anterior incision of the fascia, as Briganti experience
Briganti A.,Salonia A. et al.: EAU-EBU Update, 2006
In order to spare these anterior fibres, the surgeon should choose a more ventral incision in the mid-part as suggested similarly by Montorsi et al. with an even higher incision at the 11-1 o'clock position
Montorsi F. Salonia A. et al.:Eur Urol., 2005

11. But what is the exact distribution of periprostatic autonomic nerves ?
UROLOGY
miUlli
DEPARTMENT
But what is the exact distribution of periprostatic autonomic nerves ?

12. miUlli UROLOGY New «anatomic concepts»
DEPARTMENT
The largest percentage of periprostatic nerves is located in the dorsolateral position
Periprostatic nerve distribution is variable, with a high percentage of nerves in the ventrolateral and dorsal positon in some cases
The periprostatic nerve density decrease to the base towards the apex
A significant portion of nerves of the NVB appears to branch into the prostate
The highest density of capsular nerves is found at the apex
Ganzer R., Blana A., et coll: Eur. Urol, 2008

13. miUlli UROLOGY New «anatomic concepts»
DEPARTMENT
Therefore, it is recommended that the surgeon focus on nerve preservation in particular at the apex, starting in the anterior at the mid section as well as the common posterolateral course
Sievert KD., Hennenlotter J. et al.: Eur Urol., 2010
...the neurovascular bundle appears to be a complex confluence of nerves passing through the posterolateral main track in different inclined courses without forming a distinct bundle of parallel nerves

14. Myers RP.: Urol. Clin North Am., 2001
UROLOGY
miUlli
New «anatomic concepts»
DEPARTMENT
The role of accessory pudendal artery (APAs) in normal erectile function, and their impact on postoperative potency and eventually on continence has become a topic of increasing interest.
Some studies have shown that, when present,APAs may often represent the only arterial supply to the penis
Myers RP.: Urol. Clin North Am., 2001
Breza J., Abeserif SR. Et al .: J.Urol., 1989

15. miUlli UROLOGY New «anatomic concepts»
DEPARTMENT
Iacono e Giannella demonstrated that progressive fibrosis in the corpora cavernosa after RP results from denervation and/or an ischemic process, which is caused in turn by the ligation of anomalous pudendal artery branches or of venous plexuses that drain to or from the corpora cavernosa.
Fibrosis and the subsequent loss in elasticity and function of erectile tissue probably togheter cause erectile dysfunction
Iacono F., Giannella R. et coll.: J of Urol 2005

16. miUlli UROLOGY New «anatomic concepts»
DEPARTMENT
The Mayo clinic group emphasized in open bilateral neurovascular bundle preservation (BNVBP) during RRP the potential role of:
HAR, i.e high anterior release of the levator fascia and NVBs
surgical loupe magnification (x 4,3)
Hubanks JM, Myers RP et al: Eur Urol, 2012

17. miUlli UROLOGY New «anatomic concepts»
DEPARTMENT
«When you perform an intrafascial nerve -sparing approach or “veil of aphrodite” tecnique, you make a high lateral incision of the periprostatic fascia in order to preserve the nerve tissue within the periprostatic fascia in the lateral and ventrolateral position »
Ganzer R., Blana A., et coll: Eur. Urol, 2008

18. miUlli UROLOGY New «anatomic concepts»
DEPARTMENT
Shikanov et al analyzed the impact of the extension of the nerve-sparing procedure, comparing pts that received intrafascial nerve sparing versus extrafascial nerve preservation observing a significant advantages in term of mean potency rate at 3,6 and 12 in favour of intrafascial nerve sparing procedures
Shikanov S., Woo J et al: Urology 2009

19. miUlli UROLOGY New «anatomic concepts» DEPARTMENT
H. Huland et Al: Eur Urol 2011

20. miUlli UROLOGY DETRUSOR APRON
DEPARTMENT
The Myers detrusor apron is an extension of the anterior longitudinal smooth muscle of the bladder (detrusor) in front of the anterior commissure (isthmus) of the prostate. It is a conglomerate of groups longitudinal smooth muscle and veins. Its thickness is greater in the midline of the bladder neck. Laterally, it blends with the arch of the pelvic fascia tendon. Represents a direct continuity of the front wall of the bladder with pubis, through the puboprostatic ligaments

21. miUlli UROLOGY Pubo prostatic ligaments Detrusor apron Pelvic floor
DEPARTMENT
Pubo prostatic ligaments
Detrusor apron
Pelvic floor
CONTINENCE
ERECTION
Myers, Menon, Walz, Montorsi, Rocco et Al Eur Urol 2010

22. miUlli UROLOGY APEX DISSECTION Urethral functional lenght 1,5 – 2,4 cm
DEPARTMENT
Urethral functional lenght 1,5 – 2,4 cm
Intra apex localization near colliculus
Omega shape
Outer layer of striated muscle
Inner layer of smooth muscle
Surrounding structures do not allow for anatomic urethral dissection
H. Huland et Al: Eur Urol 2011

23. miUlli UROLOGY APEX DISSECTION
DEPARTMENT
When the prostate apex covers the urethral muscles
Shortening functional urethra
Incontinence
SE Lee et Al. Urology 2006
H. Huland et Al: Eur Urol 2011

24. miUlli UROLOGY APEX DISSECTION
DEPARTMENT
ANTERIOR WALL covered by the DVC and striated muscle detrusor apron
DORSO LATERAL WALL
made from the apex and neurovascular tissue
POSTERIOR WALL
related to medial dorsal raphe
SE Lee et Al. Urology 2006
H. Huland et Al: Eur Urol 2011

25. V shaped miUlli UROLOGY APEX DISSECTION
DEPARTMENT
ventral dissection of urethral sphincter
V shaped
SE Lee et Al. Urology 2006
H. Huland et Al: Eur Urol 2011

26. miUlli UROLOGY APEX DISSECTION
DEPARTMENT
Posterior urethra incised cranially colliculus
Ventral sutures past supported with the segment of detrusor apron
SE Lee et Al. Urology 2006
H. Huland et Al: Eur Urol 2011

27. Anatomic working angles
UROLOGY
miUlli
DEPARTMENT
Anatomic working angles ?
RRP
LRP
RALP

28. UROLOGY
miUlli
INTERFASCIAL SURGICAL PLANE
DEPARTMENT

29. UROLOGY
INTRAFASCIAL SURGICAL PLANE
miUlli
DEPARTMENT

30. UROLOGY
miUlli
NERVE SPARING
DEPARTMENT

31. UROLOGY
miUlli
ACCESSORY PUDENDAL ARTERY
DEPARTMENT

32. UROLOGY
APEX
miUlli
DEPARTMENT

33. UROLOGY
ANASTOMOSIS
miUlli
DEPARTMENT

34. miUlli UROLOGY New devices
DEPARTMENT
Some studies evaluated the difference between thermal and athermal dissection of the neurovascular bundles:
Ahlering et al compared pts receiving cautery nerve sparing versus cautery-free cavernous nerve preservation patients observing a significant advantages in favor of athermal dissection 24 mo. after the procedures.
Ahlering TE, Rodriguez E et al: J. Endourol, 2008
Samadi et al compared patients who received an anterograde cautery nerve- sparing procedure using the bipolar device with two other groups who underwent atherml dissection using clips and a «curtain» tecnique observing that mean potency rate at 3,6 and 12 were 44%, 50% and 66%, respectively.
Samadi DB, Munter P.et al: J Endourol, 2010

35. miUlli UROLOGY New devices
DEPARTMENT
Finley et al. evaluated the potential role of cold dissection of the cavernous nerves ( plus an endorectal cooling balloon cycled with 4 C°) observing a statistically significant better 12-mo potency rates
Finley DS, Osann K.: J Endourol, 2009
Kowalczyk et al reported weak statistical significant advantages in favor of patients receveing a nerve sparing tecnique without cauterysation 5 mo after RARP.
Kowalczyk KJ; Huang Acet al: Eur Urol, 2011
This study confirmed two aspects related to the nerve sparing procedure :
the effect of mechanical trauma on the function of the cavernous nerves during the early follow-up
The short time of this negative effect during the robotic procedure

36. miUlli Surgeon’s experience UROLOGY
DEPARTMENT
A common refrain from busy robotic surgeons, residents and community urologists is that
RALP IS EASY TO LEARN COMPARED TO LRP OR EVEN RRP.
Certainly, the laparoscopic surgeon may require only 12 to 20 cases to develop comfort with the platform and the steps of the procedure
J.A. Cadeddu: J. Urol., 2010
However, is this the real learning curve?
Herrel et al reported that results comparable to RRP were not attained until 150 cases and that “self-perception” of a comparable degree of comfort with RALP and RRP was not recognized until greater than 250 RALP procedures.
Herrel SD, Smith JA Jrs: Urology, 2005

37. miUlli UROLOGY MIULLI ROBOTIC CENTER RALP Volume
DEPARTMENT
MIULLI ROBOTIC CENTER
RALP Volume
Feb 2006 – Dec serie pioneristica bracci
April 2009 – Sep 2012 serie matura bracci

38. miUlli UROLOGY RALP Età media 66.5 Range 43 - 77 PSA preop media
APR 2009 – JUL 2012
600 PAZIENTI RALP
miUlli
DEPARTMENT
RALP
Età media
66.5
Range
PSA preop media
9.7 ( )
Stadio clinico
≤ T1c
86 %
≥ T2
14%
Gleason bx ≤6
63% 7
32%
≥ 8 5%
Follow-up medio
18 mesi (3 – 39)

39. miUlli UROLOGY Dati Intervento RALP Procedure 600
DEPARTMENT
RALP
Procedure
600
Durata intervento media
165 min
(90 – 390)
Tempo alla consolle
118 min
(60 – 215)
Perdite ematiche intraoperatorie
125 mL
(10 – 1200)
Nerve sparing bilaterale
NSSS ≤ 4
123
20,5%
Nerve sparing intrafasciale
NSSS = 2 48 8%

40. miUlli UROLOGY Outcomes patologici RALP Stadio patologico ≤ T2c 67%
DEPARTMENT
RALP
Stadio patologico
≤ T2c
67%
T3a
21%
T3b
11,5% T4
0,5%
Gleason score ≤6
50% 7
44%
≥ 8 6%

41. miUlli UROLOGY Outcomes patologici Linfonodi N+ 3%
DEPARTMENT
Linfonodi N+ 3%
Margini chirurgici R+
18%
Intrafasciale
10%

42. Nerve Sparing Scoring System
UROLOGY
miUlli
Perfect nerve sparing
Minor damage
Moderate damage
Complete resection
DEPARTMENT
GLOBAL NSSS ≤ 4
Nelson J Urol 2009

43. Erection Hardness Score
UROLOGY
miUlli
Erection Hardness Score
DEPARTMENT
0 Penis not enlarge
1 Penis is larger but not hard
2 Penis is hard but non enough for penetration
3 Penis is hard enough for penetration but not completely hard
4 Penis is completely hard and fully rigid
REF ≥ 3
Mulhall J Sex Med 2007

44. Residual Erectile Function Erection Hardness Score
Outcomes funzionali
UROLOGY
miUlli
Erezione
REF
Residual Erectile Function
Precoce
31%
3 mesi
60%
6 mesi
63%
9 mesi
64%
12 mesi
66%
24 mesi
68%
DEPARTMENT
Protocollo riabilitativo
PDE5-I
Erection Hardness Score
0 Penis not enlarge
1 Penis is larger but not hard
2 Penis is hard but non enough for penetration
3 Penis is hard enough for penetration but not completely hard
4 Penis is completely hard and fully rigid
REF ≥ 3
Mulhall MD 2007

45. miUlli UROLOGY Outcomes funzionali Continenza 0 pad Safety pad Precoce
DEPARTMENT
Continenza
0 pad
Safety pad
Precoce
33%
3 mesi
61%
6 mesi
68,5%
9 mesi
74,5%
12 mesi
89%
24 mesi
93%

46. miUlli UROLOGY Intrafasciale Bladder neck sparing Erezione Continenza
DEPARTMENT
Erezione
1 mese
3 mesi
77%
6 mesi
79%
1 anno
81%
Outcomes funzionali
Continenza
1 mese
97%
3 mesi
6 mesi
98%
1 anno
G.M. Ludovico S.I.U. 2012

47. Tasso globale complicanze
UROLOGY
Tasso globale complicanze
miUlli
RALP - literature
Tasso globale complicanze 1 – 21%
High volume 10%
DEPARTMENT
Miulli Clavien
Clavien I 8%
Calvien II 5%
Clavien III 0,8%
Clavien IV 0,15%

48. Tasso globale complicanze
UROLOGY
Tasso globale complicanze
miUlli
DEPARTMENT
Conversione open nessuna 0
Sanguinamento ,6%
Cateterismo prolungato 8 1,3 no V-lock
Deiscenza anastomosi nessuna 0
Stenosi Anastomosi 4 0,7% no V-lock
Embolia ,15%
Lesione retto ,15
Ematoma parete ,7%
Linfocele ,16%
Exitus nessuno 0
Follow-up breve
Post dimissione
Analisi prognostica relativa al rischio che si verificassero

49. Surgical institutional volume Anatomic working angles
UROLOGY
miUlli
CONCLUSIONS
DEPARTMENT
Surgeon experience
Surgical institutional volume
Anatomic working angles
Robotic team
Better outcomes

50. miUlli UROLOGY CONCLUSIONS
DEPARTMENT
RALP is displacing RRP as the gold standard surgical approach for clinically localised prostate cancer in the United States and is also being increasingly used in Europe and other parts of the world.
This trend has occurred despite the paucity of high-quality
evidence to support its relative superiority to more-established treatment modalities.
Recent in-depth systematic reviews of the literature have compared the results of RRP versus LRP/RALP.
Systematic review indicates that RALP is advantageous in preservation of continence and potency recovery
Ficarra V, Eur Urol 2012.
Coelho RF;J Endourol 2010.
Kang DC, Eur Urol 2010.

51. miUlli UROLOGY CONCLUSIONS
DEPARTMENT
Currently the best treatment is to continue to perform and perfect a good bilateral nerve-sparing technique
Major modification in surgical technique (intrafascial RALP) appear to be promising
Men who undergo this procedure have a reasonable chance of regaining complete erectile function in 12 to 24 months.

52. UROLOGY
miUlli
DEPARTMENT